Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale School of Nursing Digital eses School of Nursing January 2013 e Lived Experience Of Inpatients On Contact Precautions Amanda L. Ray Yale University, [email protected]Follow this and additional works at: hp://elischolar.library.yale.edu/ysndt is Open Access esis is brought to you for free and open access by the School of Nursing at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale School of Nursing Digital eses by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. Recommended Citation Ray, Amanda L., "e Lived Experience Of Inpatients On Contact Precautions" (2013). Yale School of Nursing Digital eses. 1010. hp://elischolar.library.yale.edu/ysndt/1010
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Yale UniversityEliScholar – A Digital Platform for Scholarly Publishing at Yale
Yale School of Nursing Digital Theses School of Nursing
January 2013
The Lived Experience Of Inpatients On ContactPrecautionsAmanda L. RayYale University, [email protected]
Follow this and additional works at: http://elischolar.library.yale.edu/ysndt
This Open Access Thesis is brought to you for free and open access by the School of Nursing at EliScholar – A Digital Platform for Scholarly Publishingat Yale. It has been accepted for inclusion in Yale School of Nursing Digital Theses by an authorized administrator of EliScholar – A Digital Platform forScholarly Publishing at Yale. For more information, please contact [email protected].
Recommended CitationRay, Amanda L., "The Lived Experience Of Inpatients On Contact Precautions" (2013). Yale School of Nursing Digital Theses. 1010.http://elischolar.library.yale.edu/ysndt/1010
Permission for photocopying or microfilming of The Lived Experience
of Inpatients on Contact Precautions for the purpose of individual scholarly
consultation or reference is hereby granted by the author. This permission is
not to be interpreted as affecting publication of this work or otherwise placing
it in the public domain, and the author reserves all rights of ownership
guaranteed under common law protection of unpublished manuscripts.
________________________________________________
Amanda L. Ray, RN, MSN Candidate 2013
Date: ___________________________________________
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May 6, 2013
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Acknowledgements
The author thanks her thesis advisor Dr. Laura Andrews for her
direction and support. The author also recognizes and thanks Yale-New
Haven Hospital and its Director of Nursing Research Dr. Janet Parkosewich
for their support in data collection and the conduction of interviews. No
funding was provided for this research.
v
ABSTRACT
THE LIVED EXPERIENCE OF INPATIENTS ON CONTACT
PRECAUTIONS
This phenomenological study was designed to explore the experiences
and perceptions of patients on contact isolation precautions. Studies show
mixed compliance rates among healthcare-workers, increased workload for
staff, less time spent at the bedside, higher rates of adverse events, and higher
rates of anxiety and depression for patients on contact precautions. Few, if
any, studies describe the perception of contact precautions in patients’ own
words. Interviews were conducted and analyzed using Colaizzi’s (1978)
method for qualitative analysis. Themes identified included patient’s
understanding of contact precautions, cleanliness and dirtiness, family and
visitor perceptions, patient priorities, delays in care and staff attitudes, and
protecting not isolating. Examination of these themes indicates that contact
precautions are not perceived as burdensome, isolating, or distressing by most
patients. Patients may even perceive precautions as protecting them from the
hospital environment. Patients should be reminded of the indications for
contact precautions often during their hospital stay. Families and patients
showing signs of distress should be supported with information about
transmission risks, infectious status, and the use of contact precautions
routinely and frequently during a hospital stay. Staff compliance with contact
precautions is regularly observed and analyzed by patients as reflective of
hospital cleanliness.
vi
TABLE OF CONTENTS
Chapter Page I. THE CLINICAL PROBLEM …………….……….………….… 1
Introduction ……………………………………..…...........…1 Review of Literature …………………………….…..............3 History …………………………….....….……..……3 Isolation of contact-transmitted infections …..….......3
Compliance Data ….……………..…………..…….10 The Burden ….…………………..…………………14 Research Question ….…………..………………….24 Operational Definitions ……………………………24
II. RESEARCH METHODS …...……………………………….....26
Design ...…………………………………………………….26 Sample and Setting ...……………………………….............26 Procedure ...…………………………………………….…...26 Data Analysis ...………………………………………..……27
III. RESULTS ...………………………………..…………………...29
Analysis of Themes ...………………………………………29 Patient’s Understanding of Contact Precautions ..…...29 Cleanliness and Dirtiness ………...…………….……32 Family and Visitor Perception …………..…….…….35 Patient Priorities ……….……………….………...….36 Delays in Care and Staff Attitudes …....……….…….40 Protecting Not Isolating ………………..……………43 Formulated Statement of Experience ………..….…………..46
IV. DISCUSSION ……………..………………………………….…49
Patient’s Understanding of Contact Precautions …….49 Cleanliness and Dirtiness …………….…...…………51 Family and Visitor Perception ……………………....52 Patient Priorities ………………..……………..……..53 Delays in Care and Staff Attitudes …………………..57 Protecting Not Isolating ………..……………………58 Limitations ……………………………....…………………..59
Conclusions and Implications for Practice and Research …...59
REFERENCES ……………………………………...………………………61
APPENDIX ………………………………………………………………….71
vii
List of tables
Table Page
1. Summary of Key Studies in Literature …………………………….….. 17 2. Summary of Literature Reviews ……………………………………… 22 3. Steps for Colaizzi’s Method of Phenomenological Analysis ……......... 28 4. Themes with Illustrative Patient Statements ………………………….... 45
1
CHAPTER I: The Clinical Problem
Introduction
Contact precautions aim to prevent exposure of vulnerable patients, visitors,
and health-care workers to potentially virulent or lethal infections by interrupting the
method of bacterial transmission (Siegel, Rhinehart, Jackson, Chiarello, & the
Healthcare Infection Control Practices Advisory Committee, 2006, 2007). They
involve, at minimum, an impervious gown and gloves to protect body and clothing
from contamination. Signs and equipment are commonly placed by a patient’s door,
and everyone entering the patient’s environment must don a gown and gloves. This
can affect every aspect of the hospital stay from transportation to meal delivery.
While understanding and compliance with contact isolation precautions have been
well studied and documented among health-care workers (Clock, Cohen, Behta, Ross,
demonstrate an increased demand on nurse staffing and a decreased amount of
nursing time spent in patient rooms as a result of contact precautions. As previously
discussed, the review of medical charts by Stelfox et al. (2003) documented an 8-fold
increase in adverse events among patients on contact precautions. Khan et al. (2006)
used a piloted survey at a large tertiary care center to investigate perceptions and
issues regarding contact precautions among healthcare workers. Almost half of
15
physicians (43%) and 26% of nurses felt that patient-care was different when patients
were on contact precautions. Sixty-three percent of physicians and 33% of nurses felt
this population was more prone to adverse effects, and 80% of physicians and 73% of
nurses felt the mood of these patients differed from that of other patients. Half of
physicians and as much as 11% of nurses felt these patients consumed “too much
time” and got inadequate attention from healthcare workers. Though nurses seemed
less inclined than physicians to report negative impacts among their patients, the
results of the questionnaire demonstrate a significant trend among healthcare workers
toward feeling differently about patients on contact precautions. If healthcare
workers perceive differences, it is possible that patients and visitors perceive
differences too. However, this has not been well-studied or documented in the
literature.
One of the most frequently cited studies regarding the psychological impact of
contact isolation precautions is Gammon’s (1998) quasi-experimental analysis of
anxiety, depression, self-esteem, and sense of control among isolated and non-
isolated patients. Using standardized scales and questionnaires for each
measurement, Gammon (1998) determined that while many individuals experience
detrimental psychological effects from hospitalization, infected isolated patients
experience significantly higher rates of anxiety and depression as well as lower
feelings of self-esteem and sense of control. Though this study is widely cited for its
simple design and clear results, the subject sample is small (forty) and elderly, and it
does not take into account the severity of illness experienced by participants.
Though still frequently cited, this study was also conducted over a decade ago in a
rapidly changing healthcare environment. The results may very well be outdated in
16
the current healthcare climate which allows patients to ambulate outside of their
rooms while on contact precautions (Yale-New Haven Hospital, 2011), allows for
cohorting of patients, and allows the use of precautions for colonized patients without
active infection.
Though no control was used in their preliminary study to compare the
prevalence of mood disturbances in contact precautions patients, Davies and Rees
(2000) documented the existence of anxiety and depression using standardized
questionnaires. Patients preferred to have the investigators fill out the questionnaires
interview style rather than complete them independently. Though the research was
conducted as a pilot study to a larger examination of the impacts of contact
precautions, the researchers documented that 33% of the studied patients suffered
from anxiety and/or depression. They concluded that this was at least twice the rate
of depression and anxiety documented in the contemporary literature for hospitalized
patients in general. One of the criticisms of both psychometric studies of contact
precautions as well as studies that assess morbidity related to MDRO infections is
that the studies often do not take into account severity of illness when comparing
patient populations. Similar to the limitation cited in the literature review conducted
by Morgan et al. (2009), Gammon (1998) and Davies and Rees (2000) cite neglect of
proper severity-of-illness controls as one of the largest limitations of their studies.
At least one study regarding the negative psychological impact of contact
precautions has attempted to address the problem of severity-of-illness controls and
cohorts. Catalano et al. (2003) used the Hamilton Anxiety and Depression Rating
Scales to determine the rates of anxiety and depression in hospitalized patients not
critically ill on contact precautions. Though the sample was small (24 and 27
17
participants in control and isolation groups, respectively), they concluded that contact
isolation directly correlated with increased rates of anxiety and depression. A similar
study conducted by Tarzi, Kennedy, and Stone (2001) examined anxiety and
depression rates in forty elderly rehabilitation patients, half of whom were on contact
precautions. They concluded that the isolated patients experienced higher rates of
anxiety and depression as a direct result of their contact precautions status. Though
these are not the only studies indicating higher rates of depression, anxiety, and anger,
they are routinely cited in the literature and fairly representative of current studies.
The problem with using questionnaires and scales, however, is that no one is talking
to the patients directly to understand the root causes of their distress.
Table 1 Summary of Key Studies in Literature
Author(s), Year
Purpose Design and Methods
Findings
Catalano et al., 2003
To assess rates of anxiety and depression in patients who are not critically ill and are placed in isolation.
Observational study, non-ICU VRE/MRSA patients compared to non-infectious patients using Hamilton Anxiety and Depression Rating Scales (n=51)
Non-isolated patients had noticeable improvement in anxiety/depression scores during hospitalization, but isolated patients did not. There were also significant differences in baseline scores between the two groups.
Davies & Rees (2000)
To determine the presence of mood disturbances in source-isolation patients
Interview based questionnaires of contact isolated patients, (n=21)
Isolated patients have higher rates of depression and anxiety than comparable patients. Often these mood disturbances are under-recognized by nurses
18
Gammon, 1998
To investigate if isolation because of an infection was more stressful than routine hospital admission
Quasi-experimental surveys using Hospital Anxiety and Depression Scale, Health Illness (Powerlessness) Questionnaire, Self Esteem Scale (n=40)
Hospitalization results in negative feelings that have detrimental effects on psychological well-being and coping. Isolated subjects had higher rates of anxiety and depression, and lower self-esteem.
Gasink et al., 2008
To study of the effects of contact isolation on patient satisfaction
Cross-sectional survey using CAHPS surveys (n=84)
Most patients lack knowledge regarding isolation but feel it improves their care. They are not less satisfied with care than non-isolated patients
Khan et al., 2006
To determine the impact of contact isolation on health care workers
Mailed questionnaires to nursing and physician staff (n=155)
Physicians were more likely than nurses to believe there was a difference in care provided to isolated patients as compared to non-isolated patients, believe that these patients consumed too much time, believe that they were more prone to adverse events and effects, and believe that they did not get adequate attention. Both nurses and physicians were concerned about contracting infection and perceived a difference in mood in isolated patients.
Knowles, 1993
To explore the perception of isolation form patient and nursing viewpoints
Phenomenology study, interviews with patients (n=8) and their nurses
Some patients valued privacy, solitude, and control of the situation. Expressions of neglect and isolation were common. Some patients perceived stigmatization and loneliness. Nurses citied time, environmental constraints, and fear of infection as limitations on interventions.
19
Rees, Davis, Birchall, & Price, 2000
To investigate relationships between mood, patient-satisfaction, and quality-of-care factors among isolation patients in acute & rehabilitation settings
Audit-style evaluation of interview based questionnaires of contact isolated patients, (n=21)
Mood disturbances existed in isolated patients. Patients were generally satisfied with care and surroundings. Factors associated with satisfaction included being kept up to date with plan of care, having a comfortable environment and good communication with staff.
Stelfox et al., 2003
To examine the quality of medical care received by patients isolated for infection control
General cohort (n=156) and CHF- cohort (n=144) compared to isolated patients (n=78 and n=72 respectively) examining quality of care measures, outcomes, and patient satisfaction
Isolated patients were twice as likely to have adverse events, eight times as likely to experience preventable adverse events. Isolated patients more likely to complain to the hospital about their care, have fewer vital signs recorded, and more days without a physician note in their chart. No differences in hospital mortality were observed, no differences between CHF and general cohorts determined.
Tarzi et al., 2001
To investigate the impact of hospitalization and MRSA isolation on the psychological functioning of older adults undergoing rehabilitation
Cross-sectional matched control study using questionnaires on depression, anxiety and anger (n= 22 MRSA patients, n=20 control patients)
All participants had higher rates of anger than non-hospitalized pts. MRSA patients had higher anxiety and depression scores than non-MRSA patients. No correlation between length of hospitalization or duration of precautions.
Wilkins, Ellis, Dunbar, & Gibbs, 1988
To determine if isolated patients experience more mood disturbances than non-isolated patients
Interviews with patients on infectious disease ward (n=41)
Isolation was not found to be disconcerting to patients. Isolated patients experienced higher rates of anxiety, but this appeared to be related to illness and hospitalization, not to isolation
20
Though fewer in number and less frequently cited, studies exist indicating that
patients are not negatively impacted by contact precautions. Using the standardized
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey conducted in person, Gasink et al. (2008) found that isolated patients did not
report any less satisfaction with care than non-isolated patients. Though not part of
the protocol, the authors informally observed that many patients felt that isolation
precautions improved their care. They also reported that patients on contact
precautions lacked education and knowledge regarding isolation. Abad et al. (2010)
mention additional studies drawing these conclusions, but they target pediatric
populations and thus will not be discussed here. There also exists a more detailed but
outdated study by Wilkins, Ellis, Dunbar, and Gibbs (1988) that conducted interviews
with isolated patients on an infectious disease unit. They determined that isolation
was not found to be disconcerting to patients. Isolated patients did experience higher
rates of anxiety than the general population, but this appeared to be related to acute
illness and hospitalization and not related to isolation. Despite its rigorous
methodology, this study is not routinely cited in the literature, likely due to its age
and qualitative nature.
Anecdotes from healthcare workers are numerous and represent their
perspectives as both caregivers and, occasionally, as patients on isolation precautions.
Hass (2010) describes the loss of therapeutic and diagnostic touch when interacting
with his patients in his personal narrative as a physician who developed a MRSA
infection after direct contact with patients. Oldman-Pritchard (2003), a nurse,
describes her experience as a patient on neutropenic isolation precautions as
21
“tortuous” and lonely. These narratives highlight the awareness among the medical
profession that patients on contact precautions crave human interaction and physical
touch and that they suffer psychological consequences from the deprivation. Hass’s
(2010) essay, in particular, explains the health-care worker point of view taken while
providing care. As narratives, however, these anecdotes can only serve as glimpses
rather than exhaustive descriptions representative of the whole experience of the
population.
A current comprehensive description of the patient experience is lacking in
the literature. In 1993, Knowles interviewed eight patients and their nurses to
examine their perceptions of patient isolation. Often cited in the literature, the small
London study revealed that patient attitude toward precautions varies. Some patients
in the study appreciated the solitude and privacy provided by the isolation and voiced
feelings of control the situation provided. Other patients felt stigmatized, neglected
by the nursing staff, and lonely. These latter patients’ experiences were bolstered by
nurses’ perceptions that constraints on time, physical environment, and the fear of
infection limited nursing interventions to alleviate this response. While Knowles
(1993) began to shed light on the phenomenon, the study is now outdated. At the
time and location where the study was conducted, the patients were either nursed in
wards (large rooms with more than twenty patients) or in single rooms that they were
not allowed to leave as part of their isolation. Contact precautions and hospital
design have greatly changed since this study was conducted. Wards are less common
and cohorting contact precautions patients has become more common in many
hospitals. Though Knowles (1993) is still cited frequently in literature as evidence
22
for patients feeling negatively about contact isolation, no other studies have been
done that attempt to reproduce or expand on the results.
Health care delivery in the U.S. has undergone rapid progression and
institutional change over the past few decades, possibly rendering other studies
outdated as well. The age of most phenomenological studies, the geographical
limitations of these studies, and the loosely specified results all contribute to the lack
of a generalized understanding of the patient experience of contact isolation
precautions. Without a clear understanding of this experience, it becomes almost
impossible to target interventions that will improve psychological or physiological
outcomes for these patients and the institutions that care for them.
Table 2 Summary of Literature Reviews
Author(s), Year
Purpose Design and Methods
Findings
Abad et al., 2010
To determine whether contact isolation leads to psychological or physical problems for patients
Systematic Review, 15 studies
The majority of studies showed negative impact on patient mental well-being and behavior as increased depression, anxiety, and anger scores. Studies showed less time spent in patient care and increases in adverse events.
Aboelela et al., 2006
A review of recommendations, guidelines, and evidence regarding barrier precautions, patient isolation, and surveillance cultures to prevent MDRO transmission
Systematic Review, 29 studies, 7 of high quality
Key knowledge gaps identified: need for greater monitoring of intervention implementation, more cost analyses of interventions, independent contribution of specific interventions, and identifying minimum interventions necessary.
23
Backman et al., 2011
To review and critique the literature on the relationship between an MDRO infection and control program and MDRO rates in acute care hospitals
Metanalysis of 32 studies
Evidence of a relationship between MDRO infection control programs and rates of MDRO transmission is weak. Overall evidence does support use of multiple interventions to reduce MDRO infections in acute care hospitals. It is unclear which bundles of interventions are effective, but multiple simultaneous interventions can be effective. Despite limitations, studies associate active surveillance cultures with reduced MDRO infections.
Gammon, 1999
To define and examine historical developments of source isolation and discuss possible effects on psychological well-being
Historical references of source isolation, Literature Review of 5 relevant studies
There is a lack of research on psychological effects of source isolation, though related research suggests negative effects of isolation on psychological well-being.
Jones, 2010
To explore the effects of isolation based on themes: 1) isolation environment and psychological care, 2) stigma of MRSA, 3) nursing care
Literature Review, number of studies not cited, 12 presumed
Themes identified in the literature include patient frustration, separation from others, inability to see staff, lack of activities for distraction, increased attention seeking, anxiety, sensory deprivation, depression, increased behavioral effects with length of precautions, nurse prejudice, stigmatization, inconsistent information sharing, solitude, feeling dirty/unclean, fear of family infection, "not feeling different" due to asymptomatic status, knowledge deficiency and mixed messages.
24
Research Question
What is the lived experience of hospitalized patients on contact isolation
precautions?
Operational Definitions
Lived experience is a phenomenology term used to describe the everyday
experiences and perceptions of a given group of individuals, and to give meaning to
each subject’s perception of the particular situation or event in terms of his/her
environment, body, time, and relationships with others. In health research, the group
in question usually is defined as sharing a specific health diagnosis or symptom (Polit
& Beck, 2008).
This study looks at the lived experience of hospitalized inpatients. The term
inpatient refers to any patient that is admitted to a hospital or healthcare facility and
assigned to a bed while undergoing a procedure or diagnosis, or receiving treatment
and care (Inpatient, 2008). More specifically, this study looks at inpatients placed on
contact isolation precautions.
Morgan et al., 2009
To review studies and reports of "worse noninfectious outcomes" in patients placed on contact precautions.
Literature review, 15studies, 9 high quality
Four main adverse outcomes related to contact precautions: 1) less patient/Healthcare-worker contact, 2) changes in systems of care that produce delays and more noninfectious adverse events, 3) increased symptoms of depression and anxiety, 4) decreased patient satisfaction with care
25
The definition of contact precautions states that any entrant to an infected or
colonized individual’s room must wear an impervious gown and gloves that must be
discarded before exiting the room. Contact precautions differ from standard
precautions, such as hand-washing, in that they are not routinely used on every
patient but are used in a specific subset of the patient population as identified by an
institution’s specific infection control policy.
26
CHAPTER II: Research Methods
Design
The purpose of this qualitative study was to examine the lived experience of
hospitalized patients on contact precautions. Patients were interviewed and the
resulting data analyzed using Colaizzi’s (1978) method of phenomenology.
Sample and Setting
Participants were recruited from medical and surgical inpatient units at an
academic tertiary care hospital in New England. Eligible subjects were 18 years or
older and included alert and oriented patients on contact precautions for greater than
72 hours, including previous hospital admissions. Subjects on additional droplet or
airborne precautions were excluded. Sampling was purposive, and subjects were
enrolled in the study until the data reached a saturation point defined as no new
themes emerging from data analysis. Ten subjects were enrolled before reaching
saturation.
Procedure
Data collection took place in the form of interviews based on the prompt:
“Tell me about your experience on contact precautions.” Interviews were audio
recorded and transcribed verbatim by the researcher. Research approval was acquired
from the author’s university Internal Review Board, the hospital’s primary nurse
researcher, and the respective unit managers. Nurses on the units were informed of
the study via flyers posted in conference and break rooms.
27
On scheduled days, the researcher arrived on the unit and consulted with unit
nurses to identify potential subjects and to determine each patient’s ability to consent,
level of alertness, and the number of days on contact precautions. Any patient
fulfilling the eligibility criteria was then asked by the assigned nurse if the researcher
could enter the room with further information about the study. After discussion of the
study’s goals, risks, and methods, consent from willing participants was obtained in
written form and the interviews began.
Interviews were audio recorded on a digital recorder (an Olympus Digital
Voice Recorder VN-3100PC) and transcribed using standard word processing
software without inclusion of patient identifiers. No questionnaire or preset list of
questions were used. Follow-up questions were only used for clarification of
patients’ experiences or to elicit further information. Interviews were conducted with
only the subject and researcher present and the patient’s door closed. Interviews
paused when hospital personnel or visitors needed to enter the room. Basic
biographical and contact information along with the rationale for precautions were
obtained from the patient. On the occasion when a subject was unable to clarify the
reason for the precautions, the researcher asked the nurse to identify the reason for
use. No medical records were ever accessed by the researcher.
Data Analysis
Once transcribed, interviews were analyzed using Colaizzi’s (1978) method
for phenomenological research analysis (See Table 3). An exhaustive description of
the patient experience was then mailed to study participants for feedback and
28
validation using the contact information the subject provided during the interview.
Five of the ten subjects responded, agreeing with the statement.
Table 3 Steps for Colaizzi’s Method of Phenomenological Analysis
1. Read all transcriptions twice to acquire a feeling for them. 2. Review each transcript and extract significant statements. 3. Formulate meanings from these significant statements and phrases. 4. Organize the formulated meanings into clusters of themes and validate them in the context of the original statements from the transcripts. 5. Integrate results into an exhaustive description of the phenomenon under study. 6. Formulate an exhaustive description of the phenomenon under study in as unequivocal a statement of identification as possible. 7. Ask participants about the findings thus far as a final validating step.
Note. Adapted from Polit & Beck (2008) and Colaizzi (1978)
29
CHAPTER III: Results
Analysis of Themes
Patient’s Understanding of Contact Precautions
Patients had varying levels of knowledge regarding their contact precautions
status. Six of the ten patients interviewed were able to verbalize the organisms they
were on precautions for and how contact precautions prevented transmission; the rest
were only vaguely aware of either their precaution indications or status. A few
patients verbalized simplified but accurate understandings of the pathophysiology of
the particular pathogen with which they were infected.
Four of the six patients who understood their reason for precautions knew
exactly where and when they acquired the infectious organism. All of these patients
reported that they had acquired the infection in the process of managing another
medical condition.
-‐ “I had fluid in the abdomen. They put a drain in, and that was infected. So then
they said I had MRSA.”
-‐ “Because I got my gallbladder taken out. Instead I got worse. I went in there and I
got it [C. difficile].… I used to stay in my house. I didn’t go anywhere else. I
just went to the hospital to get my gallbladder out.”
-‐ “I’ve been in probably at least fifty of these rooms since I was in a car accident 15
years ago, and it left me with [Methicillin Resistant] Staph.”
30
-‐ “I had a knee replacement, and it got infected. They had to re-open it up to scrape
it, re-close it. Seemed to go well except that I got MRSA.”
Other patients were either unaware of any infection/colonization or could not
state the indications for their contact precautions statuses. Their statements expressed
a more laissez faire attitude toward the precautions. Some of their statements:
-‐ “I’m not contagious I don’t believe…. I really don’t know why they have to wear
that thing; but they do, so that’s alright with me.”
-‐ “It’s to prevent infection and all that other business. There’s a million diseases,
whatever.”
-‐ “I don’t know how much good they do. They must have. I’m not even sure the
reason they added them.”
-‐ “I’m not sure of whatever it is. I don’t think they [the gowns] are for mosquitoes.”
-‐ “I was admitted today; and the last time I was in the hospital, they put you on
precautions for a little while. And I was taken off. Same thing at [rehabilitation
facility].... I don’t know what they were for.”
When the nurses for these patients were asked why they were on precautions,
they either guessed or did not know. For two of the patients, assigned nurses guessed
VRE, but each specifically stated that she could not recall and did not have it written
down. For a third patient, the nurse stated that the patient was colonized with a less
high-profile organism, and not one of the common discussed MDROs such as MRSA
or VRE.
As the statements above indicate, the patients who were unclear regarding
their infection or colonization status often stated or implied that they did not care why
31
they were on precautions. These patients and other patients with more awareness of
their precautions status appeared to trust the medical judgment of their care providers.
Additional statements from these patients attest to this notion:
-‐ “They must have [done] research on it saying that we needed it.”
-‐ “Well, this is a good precaution because the diseases or, you know, they’re very
very outgoing now so it’s a very very great idea.”
-‐ “[When you] get as sick as I’ve been, you go with the flow… It’s probably a good
thing. Without a doubt, it’s probably a good thing.”
Only one patient directly disagreed with the need for her precautions. This
patient was placed on precautions due to a history of MRSA infection:
I got put on contact precautions… when I had a drain infection. So I really
forgot about it when I came to the hospital, you know, on Tuesday. So they
said you have to have your own room, and you’re on the contact, so… I
probably need to have it tested to see that I don’t need to be on the
precautions…. I don’t have, you know, the drain’s out. It’s all healed up, but,
yeah, I’m still considered on precautions.
The patient was compliant with the precautions, however, and stated, “I know, like
everyone… could have MRSA Staph [sic]. You just don’t know.” Though she
questioned her need for precautions, she respected the medical staff’s institution of
precautions and continued to observe their requests whenever she left her room.
32
More than one patient described a simplified but accurate understanding of the
pathophysiology and/or spread of their infection or colonizing organism.
-‐ “It’s not air bound, you know, like if I talk to you and things like that. Only if you
touch it.”
-‐ From a patient with C. difficile, “The doctor said it’s like a ball; and when it splits,
it opens up, and you get it again. It’s just something that’s in me.”
Three patients experienced multiple hospital admissions while on contact
precautions. Repeat admissions made them keenly aware of the contact precautions
requirements and able to monitor how their caregivers observed them. As the most
experienced of these patients put it, “I think they’re all basically following the
precautions. I know all the precautions myself by now by heart, just because I’ve
been in so many hospitals and stuff.” Another patient understood that everyone
entering the room was at risk, and that his role was to ensure “the precautions [so]
that you don’t give it to the other people in the room with you.”
Cleanliness and Dirtiness
Many patients were acutely aware of sanitary procedures in the hospital as a
direct result of the precautions. Some patients commented positively on the
cleanliness of the staff, but others felt that the inconsistencies they saw made the
hospital seem an unclean or dirty place.
One patient, a nurse herself, felt reassured about infection control procedures
based on how her precautions status was initially discussed with her:
33
I think the staff’s been really good just with the basic hand-washing. You
know, there are, like, signs all over. They told me like the minute I was
admitted, ‘don’t forget to wash your hands, blah blah blah,’ and ‘gown up
when you come out.’ And then, you know, I didn’t even say ‘well I’m a nurse
already, I know you have to.’ But, you know, they were very good with that.
Another patient directly stated that he was impressed by the cleanliness of the staff:
“at shift-change in the morning, the common work-spaces over there are totally
cleaned up. Everything’s put away. Everything’s well managed by the people.”
At least three patients felt strongly enough to comment on the dirtiness they
perceived when they observed inconsistent precautions and hand-washing practices
by care providers. The same patient that complimented the staff on hand-washing
also commented, “I think the doctors aren’t as cooperative. Some of them have
walked right in; they haven’t gowned up. Others have.” She continued to state that
this made her feel “a little disappointed that they don’t pay attention to it. Because I
wonder, if they don’t gown up sometimes, how are other things? How are hand-
washing and all that?” Another patient was complimentary to the nurses but
disparaging towards his physicians: “Can’t beat the nurses I’ll tell you. The doctors,
ha, ha, forget it. They’re very sloppy, very sloppy.”
The nurses were not immune to disapproval, however:
I see nurses walk out in the hall with [gowns] on, walk back in, you
know, just not use them properly. You’re supposed to throw them
34
away inside the room. Then when you come… back in again, put on
again outside the room and then enter the room. You’re not allowed to
leave the room. That’s how you cross-contaminate… bacterias [sic]
and stuff like that.”
This patient had a lengthy history of hospitalizations involving contact precautions at
multiple institutions. She was very concerned that the inconsistencies she observed
among staff that cared for her might lead to another person acquiring her MRSA
infection: “I can’t spare any part in as far as cross-contamination with things like
that.” Her overall impression of the inconsistencies:
It just makes the hospital not as clean as it used to be, like years ago.
Like when they used to clean the rooms they would really clean the
rooms really good. Not just come in and dust the pictures and that. I
never see them washing the beds down or anything like that.
She also noted the inherent problem with waiting for the results of cultures: “It takes
a couple days to come back; and after that time, you seen that person already without
a gown and glove on… You’re already exposed to that line of bacteria and all that’s
going on.”
35
Family and Visitor Perceptions
The family and visitors of most patients did not voice or demonstrate concerns
to the patient regarding the contact precautions requirements. Almost all patients
either denied or did not report family or visitor distress at the idea of contact
precautions. Visitors and family were supportive of the patient and readily compliant
with institution policies.
-‐ “They feel comfortable, and they feel like they’re safer, and we don’t talk much
about that. But they feel very, very safe coming into the room.”
-‐ “I get a bit of company. But, well, they just do it [wear the gown and gloves], that’s
what they’re supposed to do, they do it.”
-‐ “Well they know they have to wear it, so…. They’re just worried if I’m going to
make it or not.”
-‐ “[If] they don’t want to wear it, they don’t have to come.”
-‐ “My friends come to see me. They have to put them on. And it doesn’t bother
them. It doesn’t bother me.”
One patient did report significant distress experienced by her family, stating
they were uncomfortable when they visited. She reported that her family was
uncomfortable in her presence at home as well. Her entire description of her
experience centered around uncertainty and subsequent anxiety on her part as well as
her family’s. Her opening statement during the interview: “I don’t care for it [the
precautions]. It upsets my family…. They don’t care for it, they don’t like it.… They
think it makes me germy…. Especially my grandchildren, they think [I’m] full of
36
germs…. They get upset with me if I take a sip of their water: ‘ew!’ you know…”
This patient could not say why she was on precautions and that the explanations of
why were “vague, very vague…. I don’t know why I’m on it now.” In this patient’s
case, her limited understanding of the reasons for her precautions made it difficult for
her to assess and explain her level of contagion. She states, “I don’t know what to tell
them.”
Patient Priorities
Many patients felt that precautions were just “part of the experience” of being
hospitalized. In other words, the precautions were not a separate part of the hospital
experience, nor were they the patient or family’s focus. Two patients did prioritize
their experience on contact precautions during the interview as a manifestation of
their overall health status. Another patient focused on the precautions as central to
her experience and a nuisance, but not as a reflection of her health status.
Most of the patients interviewed commented that not having to wear the
gowns themselves made them relatively unaware of the inconvenience: “It doesn’t
bother me in the least. I don’t have to wear it, I don’t have to put up with it, so it’s
not an inconvenience to me.” “Yellow gowns, I mean I don’t know what they’re
called. If you had them [on] long enough, they’re worth the money.”
When asked how long she had been on precautions, another patient replied,
“About the time that I was getting sick. I don’t think I had ever put one on… I really
don’t have much experience with them [the gowns]… I just see people coming in
with them on.” When asked if she had anything she would tell other patients about
37
her experience on contact precautions, another patient responded, “Oh, I wouldn’t get
excited about it.” To these patients, gowns are a passive experience rather than an
active one. As one patient summarized, “[When you] get as sick as I’ve been, you go
with the flow. You don’t worry about the cost of anything. What are you going to do
next to get me better? You just go with the flow.”
One patient with an active MRSA infection put it more subtly. “I have
another… infection. They don’t know if that came from the PICC line, or wherever.
They did pull that. [The nurse] explained it to me. I can’t remember… anymore.” In
this statement, the patient is referencing the fact that it was explained to him, but that
his focus was not on remembering the details of the infectious agent. His mind was
on the fact that he had an infection and on his overall physical and health status. He
focused more on the treatment and prognosis than the causes or inconveniences of his
infections.
When pressed, another gentleman was frankly surprised at the inquiry about
his experience with precautions and specifically the fact that people had to gown up
before entering his room:
I don’t care. I could care less what they’re wearing [when they enter my
room]… I have no problem with that, I mean that’s up to them. They can
either put it on or take it off. I’m not contagious, I don’t believe.
He proceeded to unequivocally agree that the need for gowns and gloves was not his
priority during his hospitalization. He did not seem concerned either way about his
precautions status. This may explain why some patients are not sure why they are on
38
precautions. While the purpose of the precautions may or may not have been
explained to them, these patients are not focused on the precautions as much as on
their own prognosis and symptoms. More than one patient kept reverting back to his
or her own health status, which clearly preoccupied most minds: “I just don’t want to
go for another operation, that’s all.”
Three of the ten patients did focus on their precautions status. One of these
three was a patient with recurrent C. difficile infection. She discussed the illness and
how it made her feel debilitated and sick, but she did not talk about isolation. She
repeated statements such as, “I’m just trying to figure out ‘why’…. I mean, I don’t
do anything bad. I’m just trying to figure out why I have everything else.” When
asked about how her family felt about the precautions, she pointed out that they too
were focused on her health status and not the precautions: “Well they know they have
to wear it, so [they do]…. It’s not that. They’re just worried if I’m going to make it
or not.” In response to a question about her health status and prognosis, her answer
was: “Let me tell you, it’s a long haul.” She could clearly verbalize the need for
contact precautions, but her statements centered around her illness and health rather
than any direct impact the isolation precautions may have had on her.
Another patient on precautions for an obscure organism that was not clear to
either the patient or her nurse appeared focused on the precautions because she had
few answers about her health status. It was causing strain on her family. Regarding
contact precautions, she and her family “think it makes me germy…. Especially my
grandchildren, they think [I’m] full of germs.… They get upset with me if I take a sip
of their water: ‘ew!’ you know.” To this patient, the precautions represented a
39
knowledge barrier and a manifestation of illness. Her priority was on understanding
how her infectious status would impact her activities of daily life.
The last patient focused on her precautions as burdensome, but did not see
them as a manifestation of her health status. In fact, she saw her infectious status as
resolved, making the precautions unnecessary. This patient was on precautions for a
history of infection:
I got put on contact precautions… when I had a drain infection. So I
really forgot about it when I came to the hospital, you know, on
Tuesday. So they said you have to have your own room and you’re on
the contact…. I probably need to have it tested to see that I don’t need
to be on the precautions…. The drain’s out, it’s all healed up, but,
yeah, I’m still considered on precautions.
This patient found the gowns annoying when she was required to use them every time
she went out of the room to walk, which she was encouraged to do frequently:
A little thing, like just to walk, you know. I take a couple walks every
hour, so it’s like gowning up every so often... I know it’s just a thing
that they have to do. It’s just more irritating for me like when you
want to just take a walk out in the hall you got to gown up and all
that…. And it’s just a pain gowning up every time you have to go out
of the room, you know, to walk in the hall and do anything.
40
Taken in context with the multiple people who commented that the gowns did not
bother them because they were not required to wear them, it appears that patients are
more inconvenienced if they are mobile and want to leave their room than patients
who are sicker and are relatively limited in their mobility.
Delays in Care and Staff Attitudes
Few comments were made indicating delays in care or staff attitudes
regarding gowning and gloving. Most patients either insisted that the staff were
friendly and accommodating or simply denied any delays or negative experiences in
their care. When pressed, some patients admitted to noticing displeasure by staff
members if they had to repeatedly leave and re-enter a precautions room.
One patient stated, when asked how she felt about any perceived negative
attitude towards gowning and gloving by staff, “I guess it doesn’t bother me
particularly. I’ve been here so long I’m getting used to it.” Another patient
specifically stated that the nurses addressed his every need. “The nurses, can’t beat
them…. Anything you ask for they get for you.” Yet another patient noted that she
did not think any staff expressed displeasure or annoyance toward gowning and
gloving prior to entering. She felt that healthcare workers were invested in stopping
the spread of infection to themselves at the very least. “I think they’re more
concerned that they don’t get sick…. And they don’t shun you or anything. They
care, you know.”
One patient who had stayed in multiple hospitals while on contact precautions
noted that, “I find really on this floor nobody has about any problem at all. And
they’re really nice…. But like I said, I have been on other floors where they just, you
41
know, they don’t want to put it on.” She later quantified, “Well, I haven’t found that
[negative attitude] this time. I have found it a few times, but I haven’t found it
recently. I’m usually hospitalized about three times a year.” This patient also related
an instance of someone refusing to touch her:
I did have one surgeon once that used to come in the room and used to
stand in the door, you know. I mean… his bedside manner was so
rude… You know, and he was my surgeon that did my back surgery.
She pointed out that other than this instance:
I find all the doctors and everything are really great about it.
Especially shaking hands and stuff like that… They have gloves on,
you know, of course, but I mean, yeah. They won’t stand like ten feet
away from you like they’re afraid of you.
Patients did notice occasional displeasure by staff, but it did not appear to
have a lasting impact on them. One patient, when asked for clarification, did admit to
sensing some negativity in the staff:
I think they get upset if they have to keep putting it on and off.
Annoyed. In one sitting, if they have to go back in they have to put it
on again. But I don’t know, I’m just guessing…. I don’t study them
necessarily, but I think it’s just one more thing they got to do.
42
One patient noticed that having to gown increased the workload for hospital
personnel. “I just say for time’s sake, because I know it takes awhile to gown up.… I
do that to the dietary aide, ‘Don’t bother [to] gown, I’ll just get the tray from the
door.’“ She also felt it was her responsibility to warn the staff member in advance of
anything she might need prior to entering the room to decrease the number of times
gowns were worn and removed:
I think I’m key to asking everybody to do everything at once instead of
having to make trips back and forth…. If I was working on the floor, I
would just make sure I ask the [contact precautions] patient
everything, you know, ‘Do you need anything else because if we come
in and gown up so to make it easier for you so you don’t have to wait,
tell me everything that you need at once….’ Because you can go in
and out, in and out every few minutes with something.
Though the patient denied experiencing any delays in her care, she appears to be
proactively addressing the potential for them.
Only one patient referenced a specific delay in care. When asked if he ever
felt isolated by contact precautions, he stated, “Yeah, a little bit, when it comes time
to getting the food.… Because they bring it up to a segregation area, and sometimes it
doesn’t get distributed as fast as you’d like to see.” He insisted that this was the only
delay in care that he had experienced.
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Protecting Not Isolating
Regardless of their understanding of the indications for precautions, all
subjects verbalized an understanding that the precautions were to protect others from
bacteria, germs, or other organisms. At least four of the patients interviewed
observed, however, that the precautions had the additional effect of protecting
themselves from outside germs. Patients generally agreed that contact precautions
were in the best interest of everyone:
Well this is a good precaution because the diseases, you know, they’re
very, very outgoing now, so it’s a very, very great idea…. It’s what I
do, because there’s a lot of diseases; and I think it’s very, very well
that you still have that type of uniform.
From a different patient, “No, it’s probably a good thing. Without a doubt it’s
probably a good thing.” Another patient simply stated that those in his room
“…Won’t handle any bacteria, and they don’t want to get it.”
Several comments were made about the benefit of protecting the patient on
precautions from germs outside of their room:
-‐ “It’ll hide the dirt from your clothes.”
-‐ “I feel comfortable with you people putting the gloves on and the gowns on so
you’re not dragging anything in from somebody else.”
-‐ “Well, I can imagine most of the nurses and doctors all have Staph anymore.”
-‐ “[My experience has been] very good. I think it’s great. Everybody gets
protected.”
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Multiple patients touched on the issue of isolation but indirectly indicated that
they did not feel isolated: “I mean, they’re not afraid to touch me or anything like
that. You know, I don’t feel like I’m alienated against or, you know, like I’m going
to give them anything.” When the subject of “isolation” was brought up, one patient
responded, “Oh bull… No problem, everything is fine. You may sleep well tonight
because there is no problem with the gowns with me.” As related earlier, one patient
did describe a single instance of her surgeon refusing to touch her. Despite this
negative experience, the patient denied feeling isolated.
One patient, who had the opportunity to leave her room on a regular basis for
exercise, did comment on feeling vulnerable and exposed but denied feeling isolated:
I think a negative is that when you walk, and people, visitors or some of the
hospital staff (ancillary staff) that really don’t know why, like look at you
because you’re gowned up… But no one has stopped me to say, ‘Why are you
wearing the gown?’
When asked if this made her feel exposed, she replied, “Yeah, a little bit because I’m
wearing the gown; and it’s so bright yellow, you can’t miss it.” Though the patient
declined to say outright that she felt stigmatized, her word choices in expressing her
vulnerability and the attention drawn suggest she felt stigmatized, even if no one
directly questioned her. No other patients related an experience of requiring the
precautions outside of the room.
45
Table 4 Themes with Illustrative Patient Statements
Theme Example Statements
Patient’s Understanding of Contact Precautions
- “I’m not contagious I don’t believe.… I really don’t know why they have to wear that thing but they do, so that’s alright with me.” - I had fluid in the abdomen they put a drain in and that was infected. So then they said I had MRSA. - “I was admitted today, and the last time I was in the hospital, they put you on precautions for a little while. And I was taken off. Same thing at [rehabilitation facility].... I don’t know what they were for.”
Cleanliness and Dirtiness
- “I see nurses walk out in the hall with [gowns] on, walk back in, you know, just not use them properly. You’re supposed to throw them away inside the room. Then when you come… back in again, put on again outside the room and then enter the room. You’re not allowed to leave the room. That’s how you cross-contaminate…I can’t spare any part in as far as cross-contamination with things like that.” - “…A little disappointed that they don’t pay attention to it. Because I wonder, if they don’t gown up sometimes, how are other things? How are hand-washing and all that?”
Family and Visitor Perceptions
- “They feel comfortable and they feel like they’re safer and we don’t talk much about that. But they feel very very safe coming into the room.” - “It upsets my family…. They don’t care for it, they don’t like it… They think it makes me germy…. Especially my grandchildren, they think [I’m] full of germs.”
Patient Priorities
- “It doesn’t bother me in the least. I don’t have to wear it, I don’t have to put up with it, so it’s not an inconvenience to me.” - “[When you] get as sick as I’ve been, you go with the flow. You don’t worry about the cost of anything. What are you going to do next to get me better? You just go with the flow.” - “Oh, I wouldn’t get excited about it.” - “I just don’t want to go for another operation, that’s all.”
46
Formulated Statement of Experience
Themes identified as part of the experience of inpatients on contact
precautions include understanding of infection, cleanliness and dirtiness, family and
visitor perception, patient priorities, delays in care and staff attitudes, and protection
over isolation.
Patient knowledge and understanding of contact precautions varies. Patients
who acquire organisms requiring contact precautions often acquire them while in the
process of managing another medical condition (i.e. when they are exposed to the
healthcare environment). Most patients are not focused on their contact precautions
status, especially if the indications for the contact precautions do not include a
symptomatic infectious process. Patients being treated for an active infection tend to
be more knowledgeable about the indications for contact precautions but focus their
attention on their state of health and prognosis. Few patients correlate contact
Delays in Care and Staff Attitudes
- “I find all the doctors and everything are really great about it. Especially shaking hands and stuff like that… They have gloves on, you know, of course, but I mean, yeah. They won’t stand like ten feet away from you like they’re afraid of you.” - I think they get upset if they have to keep putting it on and off. Annoyed. In one sitting, if they have to go back in they have to put it on again. But I don’t know, I’m just guessing…
Protecting not Isolating
- “It’ll hide the dirt from your clothes.” - “I feel comfortable with you people putting the gloves on and the gowns on so you’re not dragging anything in from somebody else.”
47
precautions with their individual health status, prognosis, or sense of identity.
Contact precautions are rarely seen as isolating, and only occasionally viewed as
emblematic of disease state.
Most patients view the inconvenience of precautions as necessary for the
protection of everyone. These patients often have the insight that contact precautions
conversely protect them from exposure to pathogens present on the equipment, hands,
and clothing of hospital personnel and others who may enter the patient’s
environment. Patients routinely observe compliance by hospital staff and believe
their observations reflect the cleanliness/dirtiness of the hospital environment as a
whole. Perceived delays in care or negative attitudes by staff are not routinely
experienced or acknowledged by patients. Though some strain on healthcare-
workers is observed by patients, patients do not appear to internalize the behavior or
to interpret this as being a burden to the healthcare-worker.
Most visitors and family members feel comfortable sharing an environment
with patients while they are hospitalized and when they are discharged home. Among
families that experience discomfort or have doubts about physical contact with the
patient, information and knowledge about disease process and transmission risks is
lacking. These patients and family members show signs of discomfort and distress
while the patient is still hospitalized and often seek more information about the
infection and transmission risks.
Patients who leave their rooms to ambulate are required to wear contact
precautions gowns. Independent patients who leave their rooms frequently feel more
inconvenienced than those that only occasionally leave their rooms. The bright
yellow color of the gowns makes some patients feel vulnerable or exposed, and
48
possibly even stigmatized when wearing them in the hallways, though these patients
do not feel isolated, neglected, or vulnerable while in their rooms.
49
CHAPTER IV: Discussion
Patient’s Understanding of Contact Precautions
Studies regarding the effectiveness of patient education regarding contact
isolation are lacking in the literature. Good communication, however, may take the
place of targeted educational interventions resulting in increased patient comfort and
knowledge, negating the need for a study. This is consistent with Rees, Davis,
Birchall, and Price’s (2000) analysis of interview data in terms of patient satisfaction.
Though analysis of interviews in terms of mood disturbance (Davis and Rees, 2000)
identified higher rates of depression and anxiety than among non-isolated patients,
these same interviews demonstrated that patients were satisfied with the care they
were receiving as long as the nurses and medical team communicated effectively
(Rees et al., 2000).
The fact that patient knowledge and level of comfort with that knowledge
varied in these interviews is consistent with the results of the cross-sectional survey
of 86 isolated and non-isolated patients conducted by Gasink et al. in 2008. In
comparison to non-isolated patients, Gasink et al. (2008) found that patient
satisfaction scores were unaffected by contact precautions. Of note, less than half
(46.2%) of isolated patients felt the rational and procedures for their isolation were
adequately explained and 28.2% were not aware that the gown and gloves being worn
were actually required. Patients were aware that the isolation was for the benefit of
others (94.9%). Consistent with my findings, more than half (56.4%) felt isolation
benefited both others and themselves. Only three participants (7.7%) felt isolation
50
worsened the care they received, and twenty-four (61.5%) felt it improved the care
they received (Gasink et al., 2008). These results directly correlate with the
statements made by patients in interviews here.
Though patient knowledge of contact precautions varies, patients appear to be
comfortable with the level of information they are receiving. There are a few crucial
exceptions to this notion, however. One patient in my study verbalized extreme
distress regarding her lack of understanding of her infectious status. Though the
literature on contact precautions does not directly correlate increased patient and
family anxiety with poor knowledge regarding understanding of contact precautions,
Rees et al. (2000) and Knowles (1993) concluded that education and communication
between treatment team and patient is crucial for alleviating this distress. The
statements made by this patient were the entire focus of her interview, indicating a
need for focused intervention and education about her specific condition, infectious
status, and risks of transmission with her as well as her family members prior to
discharge. Unfortunately, in this patient’s case, the nurse caring for the patient
reported a lack of knowledge herself about the patient’s transmission risks and
specific organism. This demonstrates a lack of support for the nurse to carry out
effective communication with the patient regarding infection control and health
status. Nursing knowledge of infectious and contact precautions organisms is not
apparent in the literature. This makes it hard to evaluate the ability of nurses to
educate patients about infection control in relation to specific organisms, especially
organisms other than the high profile MDROs such as MRSA and VRE.
In addition to the patient who verbalized her confusion, other patients may be
candidates for more targeted education efforts as well. More than one patient
51
appeared to have been placed on precautions during the course of a prolonged
hospital stay. These patients rarely remembered the reason for their precautions in
comparison to the patients who were readmitted on contact precautions. Studies have
shown that acutely-ill patients have poor memory during hospitalizations for multiple
reasons including medications and physical and psychological distress (Bergbom,